21 November 2011

Okay, I am officially overwhelmed. I am about as well plugged in to the bureaucracy of medicine as any nonprofessional administrator can be. I am familiar with the joint commission audits, with the physician quality reporting program, with CMS core measures, with hospital compare, with HCAHPS, with meaningful use, with the hospital inpatient quality reporting program, with leapfrog and a variety of other patient safety and quality initiatives. Yet it seems that every time I turn around there is a new set of quality metrics being developed and implemented. I can't keep track of them anymore. It turns out, unsurprisingly, that our hospital is preparing for a new set of measures which will be tracked as of January 1, in addition to the measures that I was only vaguely aware of which they had already been tracking for the last 2 years.

This is, of course, the Hospital Outpatient Quality Reporting Program. You all knew about that one, right? Cause I didn't. So what this is, apparently, is yet another quality data reporting program. In these programs, the healthcare provider, in this case a hospital, is required to report their performance on certain quality performance metrics. If they comply with the reporting requirement, they receive the full payment update for their Medicare outpatient services, and if they do not report the measures, then they are penalized 2% of their Medicare outpatient dollars, a figure which can run into many millions of dollars for the typical hospital system.

It's important to understand, that at least at this time, hospitals are not being paid for how well they are performing these measures, simply for reporting them. It is not unreasonable to presume, based on experience with previous quality reporting initiatives, that ultimately payment will be linked with performance rather than just for reporting.

So what are the reported quality metrics which are relevant to emergency department care?
The existing metrics are:

Acute MI: median time to thrombolysis

Acute MI: thrombolysis within 30 min.

Acute MI: median time to transfer for PCI

Acute MI: aspirin on arrival

Acute MI: median time to ECG

Nontraumatic headache: Use of CT scan (medicare patients only)

New metrics being reported and tracked as of January 2012:

Troponin results within 60 min. for chest pain or MI patient.

CT head interpretation for acute stroke within 45 min. of arrival

Left without being seen rate

Door to Doctor time

Median time from arrival to departure for discharged patients.

Discharge instructions

Time from arrival to pain medication for long bone fractures

I have to say, somewhat reluctantly, compared to previous attempts to develop quality metrics for the emergency department, these are not terrible. I remember when we had a hard time in which we had to have given antibiotics to patients with pneumonia, which turned out to be not supported by evidence and drove overuse of antibiotics in the emergency department for patients who wound up not actually needing them. I knew one emergency department, not mentioning any names, where it became protocol to give an oral dose of antibiotics to anyone at triage who complained of a cough. These new metrics seem to focus more on ED throughput and efficiency, which is certainly a major factor given the ED overcrowding epidemic. And I don't think anybody would argue that getting a troponin back on a chest pain patient in less than 60 min. is an unreasonable expectation in this day and age.

The discharge instruction metric is interesting in and of itself. This is simply a prescriptive requirement that discharge instructions, which are curiously renamed "Transition records," contain the following data elements: major procedures and tests performed during ED visit; principal diagnosis at discharge; patient instructions; plan for follow-up care; list of new medications and changes to continued medications. Again, this does not strike me as unreasonable, and seems crafted in such a manner to compel EMR vendors to modify their standard discharge instructions to contain these fields by default.

So what is my take away from these new metrics and this program in general? Simply put, I think we are seeing the maturation of ED quality measurement and the nationalization of the concept of the emergency department dashboard. I also think that this is a continuation of the long planned trend of cost-cutting masquerading as quality management. Those hospitals that at this time are not reporting their data are already losing reimbursement from Medicare, which represents an overall savings to the program. By the time that all hospitals are on board and fully reporting the data, I anticipate that as we have seen on the inpatient side of things, payment will be linked to performance. In that setting, reimbursement will likely be withheld from those hospitals which are performing below the median or some other arbitrary percentile threshold. This moving target guarantees that at least half (or more) of the hospitals in the program will have a reduction in their reimbursement, even though they might be achieving a fairly high level of quality.

While I understand the overall crisis in healthcare costs in this country, and I understand the need to cut costs, and I also understand the need to improve standardization and quality of care, I do not like the fact that cost-cutting has essentially been piggybacked onto quality measurement. However, this appears to be an inexorable force that we are all just going to have to live with.

So, there you have it: enjoy! Another year, another set of quality metrics to measure and manage to.

8 comments:

I always wonder with things like this if the new bureaucracy added to receive these reports, crunch the data and do whatever they finally do with it, to enforce compliance and whatever else they do, costs more than they plan to save.

Vince - you hit the nail on the head. With any government funded "improvement" program there are the costs that are seen and those that are not seen. More often than not the additional bureaucracy winds up costing more than the perceived savings. For this reason, all this CMS, "quality initiatives" nonsense needs to go away ASAP. (its ok, shadowfax, take a deep breath) The vision impaired will see more money spent by the government on Medicare patients, but the enlightened will realize that overall govt spending will drop when the bureaucracy is demolished. The solution - privatization of the whole thing. (again, breathe shadowfax, breathe). Why can't all performance metrics be followed and adjudicated by the accreditation councils? You don't meet minimum requirements, you get shut down. Can't think of a better motivation than potential job loss.

There is one doctor who just has a saved sentence for ALL of his discharge instructions: "Follow-up with your doctor in two days for problem". 95% of the time, this is what his discharge instructions say in their entirety.

I think his head might explode with the new discharge instruction requirements.

What incentives do physicians have to comply with the measures? It seems like the change in reimbursement will only affect hospitals, how does the hospital get the physicians on board with all these quality initiatives?

Anon 3:26 - I don't disagree that the admin costs of the QI programs are a significant parasitic cost. They are largely borne by the hospitals, unfortunately, so to the Feds it's as if the program is free. While your idea of accreditation boards is interesting, it mostly is just outsourcing the concept to a different agency, and these agencies already exist and do a crappy job of the same concept (I'm looking at you, JCAHO!)

Anon 6:23 -The only leverage the hospital has (other than pure persuasion) is that they own the ER and if the ER docs don't align themselves with the hospitals' incentives, they'll get fired and replaced with docs who will.

I'm looking at the troponin measure that's coming down the pike, and I keep wondering: Why?? If the troponin is negative, you're going to admit for ACS rule out (i.e., consult cards). If it's positive, you're going to admit, repeat the troponin to see which way it's trending, and consult cards.

Either way, if you have a scary EKG or persistent chest pain you're sending the patient to the cath lab long before the troponin comes back.

Is this a clever way of getting us all to buy point of care troponin devices?

I should probably add that I've never worked anywhere with a door-to-troponin time reliably less than 90 minutes. Maybe that makes a difference. I'd love to hear from folks with different practice habits.

Ted -- great point. We get our troponins in about 20 min from arrival with a POCT device. I agree that for patient care it's +- for the reasons you cite. However from a point of view of patient throughput it's fantastic, since I can be calling the hospitalist for admit 30 minutes after patient arrival. So given the other efficiency elements of the incentives maybe that the the intent behind it.

How are these quality metrics vetted before they are implemented? Are there any efforts made to identify unintended consequences (like the time to antibiotic in pneumonia boondoggle) before these standards of care are pushed out to providers for implementation across the nation? Even with the effort to approve new meds more quickly, the FDA maintains a post-approval side-effect reporting process to look for unexpected adverse consequences. Perhaps we ought to have the same kind of mandated reporting and monitoring process on these performance metrics to be sure they don't do more harm than good. FickleFinger

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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